As the COVID-19 spread continues with climbing death rates and confirmed cases, providers across the health care continuum are navigating the impact on patients and staff. With older adults and those with serious medical conditions at greatest risk, palliative care stands to play a significant role during the coronavirus outbreak.
According to the U.S. Centers for Disease Control and Prevention (CDC), people at higher risk for severe illness and complications from COVID-19 are older adults and those with serious underlying medical and comorbid conditions such as cardiac illness, cancer, congestive heart failure, and pulmonary disease. With such diagnoses common among patients who need palliative care, providers are assessing the coronavirus’ potential reach and how they can respond to it.
“This is our part, our opportunity to deploy our expertise that is the scarce resource of palliative care,” Sean Morrison, M.D., chair of the Brookdale Department of Geriatrics and Palliative Medicine at Mount Sinai Medical Center in New York, said in a recent Center to Advance Palliative Care (CAPC) webinar. “We know how to care for these people, and we’re going to be called on to do it. We’re going to need a frontline workforce that has the knowledge and skills in palliative care, and we’re going to need it right now.”
With the magnitude of the COVID-19 crisis placing a strain on the health care workforce, palliative care teams nationwide are among the various medical specialties needed now more than ever, according to Diane E. Meier, M.D., director of CAPC.
“Palliative care teams are nowhere near large enough to address the suffering in the tens of millions of people who are going to turn to our health care sector for help with this virus,” Meier said. “Our job is to support our frontline clinician colleagues to gain the core essential skills — whether management of cough, management of shortness of breath, management of anxiety or agitation — in such a manner that even someone who hasn’t had any formal palliative care training can address those sources of suffering effectively.”
A common concern among providers is that the number of patients in need will exceed the limited resources available to treat them. According to a report from the Kaiser Family Foundation, about 105.5 million U.S. adults (41%) have a higher risk of developing serious illness if infected due to older age or health conditions. A challenge from the volume of need is determining when, where and how to best allocate palliative care resources such as personal protective equipment (PPE) and medical equipment and supplies.
“It’s really important to recognize that we should not be the ones determining where our need is greatest,” Morrison said. “That is going to depend on institutional priorities and leadership, our emergency departments, our critical care units and subsequently our hospital medicine services and floors. They’re the ones, along with hopefully the command structure, who will determine where we as palliative care providers are needed most. Our role is not to push back on that, but to go where we are needed and follow that.”
Limited resources — and restrictions necessary to reduce spread of the virus, such as social distancing — are leading to difficult conversations with COVID-19 patients and their families. Palliative care providers excel at navigating challenging conversations about patient goals and expectations, and can play a role in supporting front line responders as they care for coronavirus patients by lending expertise and guidance in difficult times.
“We need to be letting our health systems know where [communication resources] are, and walk them through how to get them and make them accessible,” said Morrison. “Most of our work is probably going to be through telemedicine and telephone support. That’s critical for a couple of reasons. One, it allows us to reach a lot more people. And number two, it allows us to keep our workforce, which is very scarce, healthy.”
Difficult conversations with palliative care patients may also be on the rise, as more emergency care is needed to treat COVID-19 cases. Addressing patient and family concerns might become more difficult as resources dwindle and demand rises. With a large medical need for equipment such as ventilators, palliative care patients, among others, may be at risk of not receiving the level of treatment and care they need.
“The response to those types of very predictable sources of distress will be invaluable to clinicians,” said Meier. “Whether critical care, [emergency department] or hospital medicine, those who are confronted with families — usually because patients are likely attended or very sick at that point — will be faced with explaining why they are not able to get what they might have a month ago.”
In response to communication needs, the CAPC developed a free toolkit for palliative care teams that includes communication tips, symptom management protocols, telehealth use guidance and patient and family support resources.
As the pandemic surges, future implications are still unfolding across health care settings, including for palliative care providers. The disease’s trajectory is anticipated to reach deep into palliative and hospice care settings and across the health care continuum.
“Just because we have a COVID-19 outbreak, it doesn’t mean that when we get through this serious illness has gone away,” said Morrison. “It’s still going to be there and all of those patients and families are going to need us in palliative care.”